Healthcare Provider Details

I. General information

NPI: 1174165369
Provider Name (Legal Business Name): NICHOLAS AZEVEDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2019
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SUMMIT ST FL 2
OAKLAND CA
94609-3412
US

IV. Provider business mailing address

3100 SUMMIT ST FL 2
OAKLAND CA
94609-3412
US

V. Phone/Fax

Practice location:
  • Phone: 510-869-8400
  • Fax:
Mailing address:
  • Phone: 510-869-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number140601
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: